Basic Information
| Provider Information | |||||||||
| NPI: | 1205953023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEHRENS | ||||||||
| FirstName: | BERNARDO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 1880 CARSWELL AVENUE | ||||||||
| Address2: | |||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053136506 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2007 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 006502 | NY | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 6007T | TX | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 432 | NM | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 170420701 | 05 | TX | MEDICAID | 000Q4763 | 05 | NM | MEDICAID |